Contact Information

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Mobile Phone*
Employer
Date of Birth - mm/dd/yyyy*
You DO NOT need to be a cancer survivor to apply. If you are a Cancer Survivor, which type?
  • Breast Cancer
  • Other Cancer

 

 

What items below describe you?
  • Past Retreat Week VolunSTAR
  • Retreat Attendee or Family member of Attendee
  • Regular Little Pink Volunteer Local or Remote
  • Volunteered at an event for Little Pink
  • Attended a Little Pink Event (not retreat)
  • Cancer survivor wanting to get involved
  • Held a fundraiser or event for Little Pink
  • Retreat Community 'TeamPINK' member
  • New to the Organization

Emergency Contact

Emergency Contact Name*
Emergency Contact Address
Emergency Contact City
Emergency Contact State
Emergency Contact Zip
Emergency Contact Relation*
Emergency Contact Phone*
Emergency Contact Email

Release of Liability

Assumption of Risk

I hereby acknowledge the activities associated with any recreational program or volunteer duty may involve an element of risk of injury. 
Little Pink Houses of Hope does not own, operate, or control the facilities where life enrichment activities are conducted. As a consequence, the below signed hereby acknowledges that he/she does hereby assume risk of any injury, illness, harm or damage of any type that may occur in the course of his/her own personal or his/her child’s participation in any Little Pink House of Hope program and release Little Pink Houses of Hope and its Board, Officers, Venue, Staff, and Volunteers from any liability or responsibility whatsoever.

 

Medical Treatment

I give permission to the medical personnel selected by the program director to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange related transportation for myself or child due to injury, illness, or medical emergency. In the event that I cannot or any other appointed individual cannot be reached in an emergency, I hereby give permission to the physician selected by the program director to secure and administer treatment, including hospitalization, for the above named individual.

I agree to the terms of the above Volunteer Release of Liability statements*
  • Yes
  • No

Media Release

Permission of Media

I grant permission for the above named to participate in any audio-visual, photo, interview, or multi-media event that may take place by Little Pink Houses of Hope and I (we) release everyone involved from liability or claims in association with said coverage.

Media Release

I grant permission for any photos, audio-visual footage, interviews both recorded and printed of the above named individual, to be used for publication in any multi-media or advertising format, such as brochures, websites, television, public service announcements, ads and publications with the express purpose of marketing and promoting Little Pink Houses of Hope.

Social Media Release

I grant permission for any photos, audio-visual footage, interviews both recorded and printed of the named individual, to be shared on social media by Little Pink representatives or by other retreat participants.

I agree to the terms of the above Media Release statements*
  • Yes
  • No

Licensed Driver Verification

Little Pink Houses of Hope is insured as a secondary insurance company to the vehicle owner's primary policy. While acting as a Little Pink Volunteer, this policy is designed to protect both the volunteer and Little Pink Houses of Hope.

 

Failure to abide by any of the below statements relinquishes Little Pink Houses of Hope from all damage and liability claims.

  • I agree to enforce the requirement that all passengers wear a seat belt
  • I agree not to let any elementary school students ride in the front seat of the car with passenger side airbags
  • I agree to abide by all laws of the state in which I am driving a vehicle as a LP representative
I agree to comply with above statements*
  • Yes
  • Not a Licensed Driver
If you are a licensed driver, Please enter the state and license number of your valid driver's license.

Concealed Weapons Policy

Little Pink Houses of Hope employees, volunteers or participants may not, at any time while on any property owned, leased or controlled by Little Pink Houses of Hope, including anywhere that a company business or activities are conducted, such as property locations, client locations, activity locations, restaurants, company event venues, and so forth, possess or use any weapon.

Weapons include, but are not limited to, guns, knives or swords with blades over four inches in length, explosives, and any chemical whose purpose is to cause harm to another person.

Regardless of whether an employee or participant possesses a concealed weapon permit (CCW) or is allowed by law to possess a weapon, weapons are prohibited on any company property or at any company event or activity.  They are also banned in any location in which the employee represents the company for business purposes, including those listed above.  A license to carry the weapon on company property does not supersede company policy.

I agree to comply with the Concealed Weapons Policy.
  • Yes

Confidentiality Agreement

This organization requires that strict confidentiality be maintained with respect to all information obtained by volunteers concerning the organization, as well as the clients and others they serve. 
The volunteer shall not disclose any information obtained in the course of his/her volunteer placement to any third parties without prior written consent from the organization. Strict guidelines of confidentiality must be maintained regarding all medical information to which a volunteer is exposed. Strict guidelines of confidentiality must be maintained regarding the organization as well. This includes but is not limited to information pertaining to financial status and operations such as budget information, donations of money or gifts in kind, salary information and data pertaining to clients, staff or other volunteers. 
No information concerning any volunteer will be divulged without prior written consent of the volunteer. This includes addresses, telephone numbers, background check information, etc.

Failure to comply with the confidentially policies of the organization may result in disciplinary actions, including the dismissal of the volunteer.

I understand the above and agree to uphold the confidentiality of these matters both during and following my volunteer service with the organization.*
  • Yes

Background & Reference Check

 
* I understand and give consent to have a background and reference check done.
  • Yes
1. Reference Name
1. Reference Phone
2. Reference Name
2. Reference Phone

 
 

Volunteer Information

 
 
 

Please check all volunteer opportunities in which you have interest.

You do not need to be local to our NC office to help!

HOPE for Little Pink - Volunteer Interest Areas*
  • HEART - Care Team (Sending birthday cards)
  • HEART - Intake (Calling families accepted into the program)
  • OUTREACH - Supply Drives (Collecting items needed for retreats)
  • OUTREACH - Fundraising/Collecting Donations
  • PROGRAMMING - Office Administration
  • PROGRAMMING - Assigning families for retreats (Must be local to Burlington, NC)
  • PROGRAMMING - Retreat Week Volunteer (Please select the retreats below to apply)
  • PROGRAMMING - TEAMPINK - Retreat Location Planning Team
  • EVENTS - Event Volunteering (community events)
Previous Volunteer Experience or other information about you.

 

 

**Retreat Volunteer Only

Things to remember when applying to volunteer for a retreat:

  • You must be 18 years old or older to volunteer without a guardian.  If you are 16 or 17, you may attend with an adult guardian.
  • You are required to come for the complete week.
  • You are responsible for travel to and from the retreat location.
  • We have a suggested volunteer donation of $300 for first time retreat volunteers and $100 for returning retreat volunteers.  If you are a property donor, board member, staff or retreat leader the donation is waived. This donation covers your lodging and food for the complete week.
  • All retreat week volunteers stay in one property with other volunteers for the week.  These accommodations vary based on the retreat location.

Please select any retreats you would like to apply to attend as a volunteer.  

 

If a retreat is not listed, we are no longer accepting applications for that retreat.

 

Please select any retreats for which you are available to serve.  

Thank you for serving our families!

 

Please know that we will notify you as soon as we can with your retreat assignment. Our process depends on various things and we usually cannot notify the volunteer of retreat assignment until about 4 months prior to the start of the retreat.

 

2019 VolunSTAR Retreat Weeks
  • April 27 - May 4, 2019 - Carolina Beach, NC
  • May 4 - May 11, 2019 - Scottsdale, AZ
  • May 11 - May 18, 2019 - Hatteras Island, NC
  • June 1 - June 8, 2019 - Ocean City, MD
  • June 1 - June 8, 2019 - Sedona, AZ
  • June 15 - June 22, 2019 - Key West, FL
  • June 15 - June 22, 2019 - Blue Ridge, GA
  • August 17 - August 24, 2019 - Orange Beach, AL
  • August 17 - August 24, 2019 - Emerald Isle, NC
  • September 7 - September 14, 2019 - Grand Haven, MI
  • September 14 - September 21, 2019 - Lake Tahoe, CA
  • September 14 - September 21, 2019 - Oak Island, NC
  • October 19 - October 26, 2019 - Myrtle Beach, SC
  • October 19 - October 26, 2019 - Central Coast, CA
  • November 2 - November 9, 2019 - New Smyrna Beach, FL
  • September 4 - September 11 - Manistee, MI
  • September 21 - September 28 - Temecula, CA
  • October 27 - November 3 - Buxton, NC
I would like to volunteer with:
My schedule is flexible to be a last minute addition
  • Yes

Confirmation

By dating and printing my name below, I affirm that the facts set forth in this application are true and complete.  I understand that if I am accepted as a volunteer, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.  I also understand that I may be subject to a background check.  It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability.

 
 
Signature*